| NPI | 1912419854 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2251X0800X Physical Therapist Orthopedic (Licence: VA 2305211618) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: VA 23052111618) |
| Enumeration Date | 2017-11-01 |
| Last Update Date | 2022-07-13 |